Treatment Updates - A Clinical Series for Physicians
Inhaled Corticosteroids
Medical Consultant: Elizabeth Brown, MD
Medical Editor: Mark Evans, PhD, Director of Multimedia CME, American Medical Association
Clinical Editor: Ronald Ferdman, MD, Division of Clinical Immunology & Allergy,
Children's Hospital Los Angeles
June 1997
Inhaled corticosteroids have been recommended as the primary maintenance therapy in
patients with moderate and severe persistent asthma. Recognition of the importance of
inflammation in the pathogenesis of asthma has led to the recommendation for the early use
of inhaled corticosteroids to treat persistent asthma. Corticosteroids exert multiple
effects on the pathogenesis of inflammation, including interference with arachidonic acid
metabolism and the synthesis of leukotrienes and prostaglandins, prevention of the
directed migration and activation of inflammatory cells, and increased responsiveness of
beta2-receptors of airway smooth muscle. The clinical effects of
corticosteroids include reduction in severity of symptoms, improvement in peak expiratory
flow and spirometry, diminished airway hyperresponsiveness, prevention of exacerbations
and possibly the prevention of lung remodeling.
The development of inhaled preparations of corticosteroids that are highly active
topically, with a relatively low-incidence of side effects, was a major advance in asthma
therapy. The generic names of currently available inhaled corticosteroids are
beclomethasone, flunisolide, fluticasone, and triamcinolone. The table below profiles the
recommended dosages of inhaled corticosteroids. Dosages vary with different preparations
because differences exist in the amount of medication delivered per actuation and in the
relative potency of each formulation. Beclomethasone diproprionate inhalers dispense 42
mcg per actuation, flunisolide inhalers dispense 250 mcg per inhalation, and triamcinolone
inhalers dispense 100 mcg per inhalation. Fluticasone inhalers come in three strengths: 44
mcg, 110 mcg and 220 mcg.
Estimated Comparative Daily Dosages for Inhaled Corticosteroids
ADULTS
| Drug |
Low Dose |
Medium Dose |
High Dose |
| Beclomethasone dipropionate 42 mcg/puff 84 mcg/puff
|
168-504 mcg (4-12 puffs - 42 mcg) (2-6 puffs - 84 mcg)
|
504-840 mcg (12-20 puffs - 42 mcg) (6-10 puffs - 84 mcg)
|
>840 mcg (>20 puffs - 42 mcg) (>10 puffs - 84
mcg) |
| Budesonide Turbuhaler 200 mcg/dose |
200-400 mcg (1-2 inhalations) |
400-600 mcg (2-3 inhalations) |
>600 mcg (>3 inhalations) |
| Flunisolide 250 mcg/puff |
500-1,000 mcg (2-4 puffs) |
1,000-2,000 mcg (4-8 puffs) |
>2,000 mcg (>8 puffs) |
| Fluticasone MDI: 44, 110, 220 mcg/puff DPI: 50, 100,
250 mcg/dose |
88-264 mcg (2-6 puffs - 44 mcg) or (2 puffs - 110 mcg)
(2-6 inhalations - 50 mcg) |
264-660 mcg (2-6 puffs - 110 mcg) (3-6 inhalations - 100
mcg) |
>660 mcg (>6 puffs - 110 mcg) or (>3 puffs - 220
mcg) (>6 inhalations - 100 mcg) |
| Triamcinolone acetonide 100 mcg/puff |
400-1,000 mcg (4-10 puffs) |
1,000-2,000 mcg (10-20 puffs) |
>2,000 mcg (>20 puffs) |
CHILDREN
| Drug |
Low Dose |
Medium Dose |
High Dose |
| Beclomethasone dipropionate 42 mcg/puff 84 mcg/puff
|
84-336 mcg (2-8 puffs)
|
336-672 mcg (8-16 puffs) |
>672 mcg (>16 puffs) |
| Budesonide Turbuhaler 200 mcg/dose |
100-200 mcg |
200-400 mcg (1-2 inhalations - 200 mcg) |
>400 mcg (>2 inhalations - 200 mcg) |
| Flunisolide 250 mcg/puff |
500-750 mcg (2-3 puffs) |
1,000-1,250 mcg (4-5 puffs) |
>1,250 mcg (>5 puffs) |
| Fluticasone MDI: 44, 110, 220 mcg/puff DPI: 50, 100,
250 mcg/dose |
88-176 mcg (2-4 puffs - 44 mcg) (2-4 inhalations - 50 mcg)
|
176-440 mcg (4-10 puffs - 44 mcg) or (2-4 puffs - 110 mcg)
(2-4 inhalations - 100 mcg) |
>440 mcg (>4 puffs - 110 mcg) (>4 inhalations -
100 mcg) |
| Triamcinolone acetonide 100 mcg/puff |
400-800 mcg (4-8 puffs) |
800-1,200 mcg (8-12 puffs) |
>1,200 mcg (>12 puffs) |
|
